POLICIES AND PROCEDURES: 33060 - RCR s.51(1)(a) - A licensee must have (a) an emergency plan that sets out procedures to prepare for, mitigate, respond to and recover from any emergency, including procedures for the evacuation of persons in care.
Observation: The emergency plan policy does not speak to practicing drills in order for staff and PIC to be prepared in the case of an emergency.
Corrective Action(s): Please ensure that you update your policy to include procedures for PIC and staff being prepared in the case of an emergency.
Date to be Corrected: November 9, 2020
POLICIES AND PROCEDURES: 33230 - RCR s.85(1)(b) - A licensee must do all of the following: (b) review and, if necessary, revise the policies and procedures at least once each year.
Observation: The Medication Policy has not be revised as required to reflect a change in the medication delivery system.
Corrective Action(s): Please ensure that policies and procedures are revised as necessary.
Date to be Corrected: November 9, 2020
POLICIES AND PROCEDURES: 33280 - RCR s.85(1)(d) - A licensee must do all of the following: (d) ensure that policies are implemented by employees.
Observation: Review of the medication administration records demonstrated that staff are not signing for all medications administered as per the Medication Policy.
Corrective Action(s): Please ensure that staff comply with the policies and procedures.
Date to be Corrected: November 9, 2020
HYGIENE AND COMMUNICABLE DISEASE: 35020 - RCR s.49(1) - A licensee must require all persons admitted to a community care facility to comply with the Province's immunization and tuberculosis control programs.
Observation: A review of five person in care records demonstrated that only three had evidence of compliance with the Province's immunization and tuberculosis control program.
Corrective Action(s): Please ensure that each PIC admitted to the facility comply with the Province's immunization and tuberculosis control program.
Date to be Corrected: November 9, 2020
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